Gastropericardial Fistula as a Late Complication of Laparoscopic Gastric Banding.

Laparoscopic adjustable gastric banding (LAGB) is a bariatric procedure that is being performed with increasing frequency as an alternative management option for morbid obesity. Several common complications have been reported including gastric band slippage and associated pouch dilatation, intragastric erosion of the band, gastric wall perforation, and abscess formation. We present a case of gastropericardial fistula occurring nine years after an LAGB. There have been no previous documented cases of the complication after this procedure.

Real-time CT-guided percutaneous placement of LV pacing leads.

OBJECTIVES: The aim of this study was to assess the feasibility of real-time computed tomographic (CT) imaging to guide the percutaneous placement of left ventricular (LV) leads in an animal model. BACKGROUND: Cardiac resynchronization therapy has been shown to improve morbidity and mortality in patients with chronic heart failure. However, placement of the coronary sinus lead can be challenging and may require a more aggressive surgical approach. METHODS: Nine swine were placed in a real-time CT scanner to define the safest percutaneous access strategy. Under real-time CT guidance, a 3.5-F pacing lead was placed percutaneously in the anterolateral LV epicardium (n = 6 swine) or to the posterolateral wall after the creation of intentional left pneumothorax (n = 3 swine) in a tangential (n = 12) or perpendicular (n = 1) approach. Pacing parameters and CT images were assessed during 30-min follow-up. Necropsy findings were compared with real-time CT images. RESULTS: CT imaging successfully defined the safest percutaneous access route in all 13 lead placements and guided the therapeutic creation of pneumothoraces. Needle trajectory remained within 5 mm of the access route defined on CT imaging. LV lead placement under CT guidance was successful in all attempts within 19 ± 7 min. The mean pacing thresholds was 2.5 ± 1.5 V, the mean R wave amplitude was 11.2 ± 5.6 mV, and the mean impedance was 686 ± 103 Ω and remained unchanged after tangential placement during 30-min follow-up. Although no cardiac complications were observed with tangential lead placement (12 of 12), the perpendicular approach resulted in a pericardial effusion requiring pericardiocentesis. At necropsy, CT images correlated well with the in situ pathological results. CONCLUSIONS: Percutaneous placement of LV pacing leads under CT guidance is feasible and might offer an alternative to more invasive surgical approaches in patients with complicated coronary sinus lead placement.

Management of postoperative lymphoceles after lymphadenectomy: percutaneous catheter drainage with and without povidone-iodine sclerotherapy.

PURPOSE: To report our single-center experience in managing symptomatic lymphoceles after lymphadenectomy for genitourinary and gynecologic malignancy and to compare clinical outcomes of percutaneous catheter drainage (PCD) alone versus PCD with transcatheter povidone-iodine sclerotherapy (TPIS). METHODS: The medical records of patients who presented for percutaneous drainage of pelvic lymphoceles from February 1999 to September 2007 were retrospectively reviewed. Catheters with prolonged outputs >50 cc/day were treated with TPIS. Technical success was defined as the ability to achieve complete resolution of the lymphocele. Clinical success was defined as resolution of the patient's symptoms that prompted the intervention. RESULTS: Sixty-four patients with 70 pelvic lymphoceles were treated. Forty-six patients (71.9 %) had PCD, and 18 patients (28.1 %) had multisession TPIS. The mean initial cavity size was 294.9 cc for those treated with TPIS and 228.2 cc for those treated with PCD alone (range 15-1,600) (p = 0.59). Mean duration of catheter drainage was 19 days (29 days with TPIS, 16 days with PCD, p = 0.001). Mean clinical follow-up was 22.6 months. Technical success was 74.3 % with PCD and 100 % with TPIS. Clinical success was 97 % with PCD and 100 % with TPIS. Postprocedural complications included pericatheter fluid leakage (n = 4), catheter dislodgement (n = 3), catheter occlusion (n = 9), and secondary infection of the collection (n = 4). CONCLUSION: PCD of symptomatic lymphoceles is an effective postoperative management technique. Initial cavity size is not an accurate predictor of the need for TPIS. When indicated, TPIS is safe and effective with catheter outputs >50 cc/day.

Recurrent non-small cell lung cancer: evaluation of CT-guided radiofrequency ablation as salvage therapy.

BACKGROUND: Radiofrequency ablation (RFA) is a potential application as a salvage tool after failure of surgery, chemotherapy, or radiotherapy of non-small cell lung cancer (NSCLC). Although several studies have evaluated the use of RFA in primary NSCLC, there is little literature on its potential application as a salvage tool. PURPOSE: To evaluate CT-guided RFA employed as a salvage therapy for pulmonary recurrences of NSCLC after prior treatment with chemotherapy, radiation therapy, and/or surgery. MATERIAL AND METHODS: A retrospective computer database search yielded 33 patients with biopsy proven primary NSCLC who underwent CT-guided RFA of 39 recurrent tumors following surgery, chemotherapy, and/or radiotherapy. Follow-up imaging was performed with CT and PET-CT. The endpoints of interest were progression-free survival (PFS) and time to local progression (TTLP). PFS and TTLP were compared by lesion size (<3 cm, ≥3 cm). RESULTS: The median PFS was 8 months. For patients with a tumor size <3 cm median PFS was 11 months, whereas the median PFS of patients with a tumor size ≥3 cm was 5 months. The difference did not reach statistical significance (P = 0.09). The median TTLP of all tumors was 14 months. TTLP of ablated tumors <3 cm in size was 24 months, compared to 8 months for ablated tumors ≥3 cm in size. The difference did not reach statistical significance (P = 0.07). CONCLUSION: RFA of recurrent NSCLC may be a valuable salvage tool to achieve local tumor control, especially in tumors measuring <3 cm in size.

Acute and subacute effects of irreversible electroporation on nerves: experimental study in a pig model.

PURPOSE: To evaluate whether irreversible electroporation (IRE) has the potential to damage nerves in a porcine model and to compare histopathologic findings after IRE with histopathologic findings after radiofrequency ablation (RFA). MATERIALS AND METHODS: This study was approved by the institutional animal care and use committee. Computed tomography (CT)-guided IRE of 11 porcine sciatic nerves was performed in nine pigs, and histopathologic analysis was performed on the day of ablation or 3, 6, or 14 days after ablation. In addition, acute RFA of six porcine sciatic nerves was performed in six pigs that were harvested on the day of ablation. All nerves and associated muscles and tissues were assessed for histopathologic findings consistent with athermal or thermal injury, respectively, such as axonal swelling, axonal fragmentation and loss, Wallerian degeneration, inflammatory infiltrates, Schwann cell proliferation, and coagulative necrosis. The percentage of fascicles affected was recorded. RESULTS: All nerves had an axonal injury. The percentage of affected nerve fascicles after IRE was 50%-100%. Axonal swelling and perineural inflammatory infiltrates were detectable at every time point after ablation. Axonal fragmentation and loss, macrophage infiltration, and Schwann cell proliferation were found 6 and 14 days after ablation. Distal Wallerian axonal degeneration was observed 14 days after ablation. The endoneurium and perineurium architecture remained intact in all cases. RFA specimens at the day of ablation revealed acute coagulative necrosis associated with intense basophilic staining of extracellular matrix, including collagen of the perineurium and epineurium consistent with thermal injury. CONCLUSION: IRE has the potential to damage nerves and may result in axonal swelling, fragmentation, and distal Wallerian degeneration. However, preservation of endoneurium architecture and proliferation of Schwann cells may suggest the potential for axonal regeneration. In contrast, RFA leads to thermal nerve damage, causing protein denaturation, and suggests a much lower potential for regeneration.

Bland embolization in the treatment of hepatic adenomas: preliminary experience.

The study presents preliminary, retrospective experience with bland embolization for hepatic adenomas (HAs) with the use of tris-acryl gelatin microspheres. Eight patients underwent bland embolization for biopsy-proven HAs. A biopsy specimen was taken from only one lesion when multiple lesions were present. Seventeen embolizations were performed for abdominal pain, active bleeding, or prophylaxis against bleeding. Five patients underwent multiple procedures. Technical success rate was 100%. Median follow-up was 24 months (range, 10-40 mo). No growth was observed at follow-up in any treated lesion, and many lesions (13 of 16) regressed. Bland embolization may be safely used for treatment of abdominal pain and bleeding from HAs.

Percutaneous irreversible electroporation lung ablation: preliminary results in a porcine model.

OBJECTIVE: Irreversible electroporation (IRE) uses direct electrical pulses to create permanent "pores" in cell membranes to cause cell death. In contrast to conventional modalities, IRE has a nonthermal mechanism of action. Our objective was to study the histopathological and imaging features of IRE in normal swine lung. MATERIALS AND METHODS: Eleven female swine were studied for hyperacute (8 h), acute (24 h), subacute (96 h), and chronic (3 week) effects of IRE ablation in lung. Paired unipolar IRE applicators were placed under computed tomography (CT) guidance. Some applicators were deliberately positioned near bronchovascular structures. IRE pulse delivery was synchronized with the cardiac rhythm only when ablation was performed within 2 cm of the heart. Contrast-enhanced CT scan was performed immediately before and after IRE and at 1 and 3 weeks after IRE ablation. Representative tissue was stained with hematoxylin and eosin for histopathology. RESULTS: Twenty-five ablations were created: ten hyperacute, four acute, and three subacute ablations showed alveolar edema and necrosis with necrosis of bronchial, bronchiolar, and vascular epithelium. Bronchovascular architecture was maintained. Chronic ablations showed bronchiolitis obliterans and alveolar interstitial fibrosis. Immediate post-procedure CT images showed linear or patchy density along the applicator tract. At 1 week, there was consolidation that resolved partially or completely by 3 weeks. Pneumothorax requiring chest tube developed in two animals; no significant cardiac arrhythmias were noted. CONCLUSION: Our preliminary porcine study demonstrates the nonthermal and extracellular matrix sparing mechanism of action of IRE. IRE is a potential alternative to thermal ablative modalities.

Irreversible electroporation near the heart: ventricular arrhythmias can be prevented with ECG synchronization.

OBJECTIVE: Irreversible electroporation is a nonthermal ablative tool that uses direct electrical pulses to create irreversible membrane pores and cell death. The ablation zone is surrounded by a zone of reversibly increased permeability; either zone can cause cardiac arrhythmias. Our purpose was to establish a safety profile for the use of irreversible electroporation close to the heart. MATERIALS AND METHODS: The effect of unsynchronized and synchronized (with the R wave on ECG) irreversible electroporation in swine lung and myocardium was studied in 11 pigs. Twelve lead ECG recordings were analyzed by an electrophysiologist for the presence of arrhythmia. Ventricular arrhythmias were categorized as major events. Minor events included all other dysrhythmias or ECG changes. Cardiac and lung tissue was submitted for histopathologic analysis. Electrical field modeling was performed to predict the distance from the applicators over which cells show electroporation-induced increased permeability. RESULTS: At less than or equal to 1.7 cm from the heart, fatal (major) events occurred with all unsynchronized irreversible electroporation. No major and three minor events were seen with synchronized irreversible electroporation. At more than 1.7 cm from the heart, two minor events occurred with only unsynchronized irreversible electroporation. Electrical field modeling correlates well with the clinical results, revealing increased cell membrane permeability up to 1.7 cm away from the applicators. Complete lung ablation without intervening live cells was seen. No myocardial injury was seen. CONCLUSION: Unsynchronized irreversible electroporation close to the heart can cause fatal ventricular arrhythmias. Synchronizing irreversible electroporation pulse delivery with absolute refractory period avoids significant cardiac arrhythmias.

Renal tissue ablation with irreversible electroporation: preliminary results in a porcine model.

OBJECTIVES: To evaluate the histopathologic and computed tomography imaging features associated with irreversible electroporation (IRE) ablation performed in normal porcine kidneys. IRE is a nonthermal ablative tool that uses direct electrical pulses to create permanent "pores" in cell membranes and cell death. It does not affect the extracellular matrix. METHODS: Fifteen female swine were treated with IRE using acute (<24 hours), subacute (36 hours), and chronic (3 weeks) treatment settings. Unipolar IRE applicators were placed under CT guidance. The renal pelvis/calyx was included in 18 ablations. Imaging and histopathologic follow-up were performed. RESULTS: A total of 29 ablations (19 acute, 4 subacute, and 6 chronic) were created. Acute/subacute ablations showed complete cortical necrosis without intervening live cells. The pelvic epithelium was necrotic with urothelial sloughing; pelvic extracellular matrix was intact. Chronic ablations showed cortical fibrosis, regenerating renal pelvic epithelium and intact pelvic extracellular matrix. No thermal injury, renal pelvic, or blood vessel injury was seen. Immediate postprocedure CT imaging demonstrated a hypodense nonenhancing lesion that persisted at 1 week. Of the 6 chronic lesions, 4 showed complete resolution at 3 weeks on imaging. No collecting system damage was seen. CONCLUSIONS: This preliminary porcine study demonstrates the nonthermal and connective tissue sparing mechanism of action of IRE. These features may protect against collecting system damage after IRE ablation of renal tissue. IRE could therefore play an important role in ablation of centrally located renal tumors.

Resolution of hepatic encephalopathy following hepatic artery embolization in a patient with well-differentiated neuroendocrine tumor metastatic to the liver.

Hepatic encephalopathy is considered a contraindication to hepatic artery embolization. We describe a patient with a well-differentiated neuroendocrine tumor metastatic to the liver with refractory hepatic encephalopathy and normal liver function tests. The encephalopathy was refractory to standard medical therapy with lactulose. The patient's mental status returned to baseline after three hepatic artery embolization procedures. Arteriography and ultrasound imaging before and after embolization suggest that the encephalopathy was due to arterioportal shunting causing hepatofugal portal venous flow and portosystemic shunting. In patients with a primary or metastatic well-differentiated neuroendocrine tumor whose refractory hepatic encephalopathy is due to portosystemic shunting (rather than global hepatic dysfunction secondary to tumor burden), hepatic artery embolization can be performed safely and effectively.